Provider Demographics
NPI:1245222744
Name:YOUNG, POLLY T (MD)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:T
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:#2109 EAST BAY FAMILY PRACTICE MEDICAL GROUP INC
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3210
Mailing Address - Country:US
Mailing Address - Phone:510-645-9900
Mailing Address - Fax:510-645-9919
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:#2109 EAST BAY FAMILY PRACTICE MEDICAL GROUP INC
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3210
Practice Address - Country:US
Practice Address - Phone:510-645-9900
Practice Address - Fax:510-645-9919
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG28119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAODG281190Medicaid
00A281190Medicare ID - Type Unspecified
A43614Medicare UPIN
CAODG281190Medicaid